האבולוציה של הפרעות אכילה
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האבולוציה של הפרעות אכילה

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    האבולוציה של הפרעות אכילה האבולוציה של הפרעות אכילה Presentation Transcript

    • ‫האכילה‬ ‫הפרעות‬ ‫של‬ ‫האבולוציה‬-‫סיור‬ ‫ה‬ ‫במשעולי‬ ‫מודרך‬-DSM ‫ד‬"‫גור‬ ‫איתן‬ ‫ר‬ ‫ומשקל‬ ‫אכילה‬ ‫להפרעות‬ ‫המרכז‬ ‫מנהל‬ ‫שיבא‬ ‫הרפואי‬ ‫המרכז‬,‫השומר‬ ‫תל‬
    • We study what we define walsh & Kahn 1977 ‫ותכופים‬ ‫מפליגים‬ ‫שינויים‬ ‫חלו‬ ‫האחרונים‬ ‫העשורים‬ ‫במהלך‬ ‫האכילה‬ ‫הפרעות‬ ‫של‬ ‫בהגדרות‬. •‫שונות‬ ‫אבחנות‬ ‫מדויקת‬ ‫בצורה‬ ‫לקטלג‬ ‫מהרצון‬ ‫נובע‬ ‫ההגדרות‬ ‫שינוי‬. ‫התוצאה‬: •‫בשכיחות‬ ‫משמעותיות‬ ‫לתנודות‬ ‫גורמים‬ ‫השינויים‬. •‫החולות‬"‫מדלגות‬"‫לשנייה‬ ‫אחת‬ ‫מאבחנה‬. •‫טווח‬ ‫ארוכי‬ ‫מחקרים‬ ‫ביצוע‬ ‫על‬ ‫מקשה‬.
    • ‫טיפול‬ ‫לצורך‬ ‫הכרחית‬ ‫מדויקת‬ ‫אבחנה‬ ‫האם‬? • Common language • Course • Prognosis • Specific treatment • Research • Co-morbidity • Physical complications • Insurance
    • ‫אכילה‬ ‫הפרעות‬–‫נורמטיבית‬ ‫התנהגות‬ ‫של‬ ‫הקצנה‬ •‫חוסר‬‫שביעות‬‫הרצון‬‫ממשקל‬‫הגוף‬(Body dissatisfaction and weight concern) ‫והצורה‬‫שלו‬‫הפכו‬‫בעשורים‬‫האחרונים‬‫לתופעה‬‫רחבה‬‫ונורמטיבית‬‫בקרב‬‫גברים‬‫ונשים‬ ‫בעולם‬‫המערבי‬. •‫בעקבות‬‫כך‬,‫היכולת‬‫להבחין‬‫היכן‬‫עובר‬‫הגבול‬‫בין‬‫התנהגות‬‫נורמטיבית‬‫ובין‬‫פתולוגיה‬ ‫נפשית‬‫התעמעמה‬. •‫העוצמה‬‫של‬‫חוסר‬‫שביעות‬‫הרצון‬‫והשפעתה‬‫על‬‫המצב‬‫הנפשי‬‫והגופני‬‫של‬‫המטופל‬‫יקבעו‬ ‫האם‬‫מדובר‬‫בהפרעה‬‫פתולוגית‬‫או‬‫בהתנהגות‬‫נורמטיבית‬. •‫בסקרים‬‫של‬‫אוכלוסיות‬‫בריאות‬‫מוצאים‬‫התנהגויות‬‫חריגות‬‫בתחום‬‫האכילה‬‫כגון‬: • Binge eating (3.2%), • Fasting regularly or use strict dieting (1.6%) • Purging (0.8%). •‫בקרב‬‫אוכלוסיות‬‫הנמצאות‬‫בסיכון‬‫התופעה‬‫אךף‬‫חמורה‬‫יותר‬.‫בקרב‬‫סטודנטים‬‫הלומדים‬ ‫בקולג‬'‫נמצא‬‫ש‬: • Binge eating (F-19%, M-6%), • Fasting regularly or use strict dieting (F-12%, M-3%) • Purging (F-2.7% M-1.3%).
    • ‫המודרנית‬ ‫בפסיכיאטרית‬ ‫הקלסיפיקציה‬ ‫התפתחות‬ •1840–‫הפסיכיאטרית‬ ‫התחלואה‬ ‫לכל‬ ‫אחת‬ ‫קטגוריה‬. •1880–‫נפרדות‬ ‫קטגוריות‬ ‫שבע‬ –‫מאניה‬ –‫מלנכוליה‬ –‫מונומאניה‬ –‫שיתוק‬ –‫דמנציה‬ –‫דיסומאניה‬ –‫אפילפסיה‬
    • Diagnostic and Statistical Manual of Mental Disorders ‫מחלות‬‫פסיכיאטריות‬‫נבדלות‬‫מהמחלות‬‫הגופניות‬‫בכך‬‫שאין‬‫סמנים‬ ‫אובייקטיביים‬‫פאתוגנומונים‬‫לנוכחות‬‫המחלה‬. ‫ולכן‬,‫האבחנות‬‫נסמכות‬‫על‬‫תיאור‬‫פנומנולוגי‬‫של‬‫המצב‬. The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association provides a common language and standard criteria for the classification of mental disorders.
    • DSM – I (1952) • World War II saw the large-scale involvement of US psychiatrists in the selection, processing, assessment and treatment of soldiers. • A committee that was headed by psychiatrist Brigadier General William C. Menninger developed a new classification scheme called Medical 203 that was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. • The manual was 130 pages long and listed 106 mental disorders
    • 006-580 Psychophysiologic gastrointestinal reaction This category includes such specified types of gastrointestinal disorders as: peptic-ulcer-like reaction, chronic gastritis ulcerative or mucous colitis constipation, hyperacidity pylorospasm heartburn irritable colon anorexia nervosa and so forth, in which emotional factors play a causative role. DSM – I (1952) 106 diagnoses
    • DSM – II (1968) 185 diagnoses Psychophysiology Disorders – Gastrointestinal • Peptic ulcer • Intestinal disorders • Obesity • Anorexia nervosa
    • Eating disorders – Anorexia Nervosa – Bulimia – Pica – Rumination disorder of infancy – Atypical eating disorder DSM- III (1980) 256 diagnoses
    • DSM-III-R (1987) 292 diagnoses • Categories were renamed, reorganized, and significant changes in criteria were made. • Six categories were deleted while others were added. • Controversial diagnoses such as pre-menstrual dysphoric disorder and masochistic personality disorder were considered and discarded. • Eating disorder group was not changed. • Bulimia become bulimia Nervosa.
    • Eating disorders – Anorexia Nervosa – Bulimia Nervosa – Eating disorder not otherwise specified DSM- IV (1994) 297 diagnoses
    • May 2013
    • ‫ב‬ ‫שהיו‬ ‫הבעיות‬–DSM-IV‫על‬ ‫שעבד‬ ‫העבודה‬ ‫צוות‬ ‫את‬ ‫והובילו‬ ‫ה‬DSM-5 •‫המחלוקות‬‫שהיו‬‫סביב‬‫אבחנת‬‫הפרעת‬‫האכילה‬‫הלא‬‫ספציפית‬EDNOS(‫שבעבר‬ ‫נקראה‬atypical eating disorder)‫נבעו‬‫מכך‬‫שכאשר‬‫הוצגה‬‫לראשונה‬‫הכוונה‬ ‫היתה‬‫שתשמש‬"‫סל‬"‫לשאריות‬‫של‬‫האבחנות‬‫הראשיות‬.‫בניגוד‬‫לציפיות‬‫היא‬ ‫הפכה‬‫להיות‬‫האבחנה‬‫השכיחה‬‫ביותר‬‫בקרב‬‫הפרעות‬‫האכילה‬. •40-60%‫מהחולות‬‫שאובחנו‬‫ע‬"‫י‬‫מומחים‬‫בתחום‬‫ו‬–90%‫מהחולות‬‫שאובחנו‬‫ע‬"‫י‬ ‫רופאים‬‫שאינם‬‫מומחים‬‫בתחום‬‫קיבלו‬‫את‬‫האבחנה‬EDNOS. •‫שכיחות‬‫של‬5%‫בקרב‬‫תלמידי‬‫תיכון‬ •‫שכיחות‬‫של‬4-6%‫באוכלוסיה‬‫הכללית‬ •‫נתפסה‬‫כהפרעה‬‫פחות‬‫חמורה‬‫מ‬–AN‫או‬BN •‫ישנן‬‫עדויות‬‫שבמהלך‬‫ההתפתחות‬‫של‬‫המחלה‬‫החולות‬‫הללו‬‫הופכות‬‫לחולות‬ ‫אנורקטיות‬‫או‬‫בולמיות‬. •‫ישנה‬‫הסכמה‬‫שהמהלך‬‫בד‬"‫כ‬‫פחות‬‫סוער‬‫מהאבחנות‬‫הראשיות‬,‫מהלך‬‫המחלה‬ ‫קצר‬‫יותר‬‫ולחולות‬‫סיכוי‬‫יותר‬‫טוב‬‫להחלים‬
    • ‫שנבחר‬ ‫הפתרון‬ ‫קיבוץ‬‫מחדש‬‫של‬‫כלל‬‫האבחנות‬‫הנוגעות‬‫ואכילה‬‫ללא‬‫הפרדה‬‫גילאית‬: •Pica •Rumination disorder •Avoidant/Restrictive Food Intake Disorder ‫הוספת‬‫אבחנה‬‫חדשה‬ •Binge-Eating Disorder ‫שינויים‬‫בהגדרת‬‫האבחנות‬‫כדי‬‫שיכללו‬‫חלק‬‫מהחולות‬‫שנפלו‬‫ל‬"‫סל‬"‫הכללי‬ •Anorexia nervosa •Bulimia Nervosa ‫ארגון‬‫מחדש‬‫של‬"‫סל‬"‫האבחנות‬‫הלא‬‫ספציפיות‬
    • DSM 5 • 307.52Pica )F98.3) In children (F50.8) In adults • 307.53 (F98.21) Rumination Disorder • 307.59 (F50.8) Avoidant/Restrictive Food Intake Disorder • 307.1 Anorexia Nervosa Specify whether: (F50.01) Restricting type (F50.02) Binge-eating/purging type • 307.51 (F50.2) Bulimia Nervosa • 307.51 (F50.8) Binge-Eating Disorder • 307.59 (F50.8) Other Specified Feeding or Eating Disorder • 307.50 (F50.9) Unspecified Feeding or Eating Disorder
    • Pica A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month. B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual. C. The eating behavior is not part of a culturally supported or socially normative practice. D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention. 
    • Pica - diagnostic Features • Typical substances ingested tend to vary with age and availability and might include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal or coal, ash, clay, starch, or ice. • A minimum age of 2 years is suggested for a pica diagnosis to exclude developmentally normal mouthing of objects by infants that results in ingestion.
    • Pica - associated Features Supporting Diagnosis • Deficiencies in vitamins or minerals (e.g., zinc, iron) have been reported in some instances. • pica comes to clinical attention only following general medical complications – Mechanical bowel problems – Intestinal obstruction from a bezoar – Intestinal perforation – Infections such as toxoplasmosis and toxocariasis as a result of ingesting feces or dirt – Poisoning, such as by ingestion of lead-based paint
    • Pica - development and Course • Onset of pica can occur in childhood, adolescence, or adulthood, although childhood onset is most commonly reported. • Pica can occur in otherwise normally developing children • Where in adults, it appears more likely to occur in the context of intellectual disability or other mental disorders • In pregnancy, when specific cravings (e.g., chalk or ice) might occur
    • Rumination disorder - diagnostic Criteria A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out. B. The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis). C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
    • Rumination disorder - diagnostic Criteria D. If the symptoms occur in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder] or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention.
    • Diagnostic Features • Regurgitation in rumination disorder should be frequent, occurring at least several times per week, typically daily. • Prevalence - prevalence data for rumination disorder are inconclusive, but the disorder is commonly reported to be higher in certain groups, such as individuals with intellectual disability.
    • Development and Course • Onset of rumination disorder can occur in infancy, childhood, adolescence, or adulthood. • The age at onset in infants is usually between ages 3 and 12 months. • In infants, the disorder frequently remits spontaneously, but its course can be protracted and can result in medical emergencies (e.g., severe malnutrition). • It can potentially be fatal, particularly in infancy.
    • Development and Course • Rumination disorder can have an episodic course or occur continuously until treated. • In infants, as well as in older individuals with intellectual disability (intellectual developmental disorder) or other neurodevelopmental disorders, the regurgitation and rumination behavior appears to have a self-soothing or self-stimulating function, similar to that of other repetitive motor behaviors such as head banging.
    • Risk and prognostic factors • Environmental - Psychosocial problems such as lack of stimulation, neglect, stressful life situations, and problems in the parent-child relationship may be predisposing factors in infants and young children.
    • Functional Consequences of Rumination Disorder • Malnutrition secondary to repeated regurgitation may be associated with growth delay and have a negative effect on development and learning potential. • Some older individuals with rumination disorder deliberately restrict their food intake because of the social undesirability of regurgitation. They may therefore present with weight loss or low weight. • In older children, adolescents, and adults, social functioning is more likely to be adversely affected.
    • Avoidant/Restrictive Food Intake Disorder A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). 2. Significant nutritional deficiency. 3. Dependence on enteral feeding or oral nutritional supplements. 4. Marked interference with psychosocial functioning.
    • Avoidant/Restrictive Food Intake Disorder B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one's body weight or shape is experienced. D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
    • Diagnostic Features • Avoidant/restrictive food intake disorder replaces and extends the DSM-IV diagnosis of feeding disorder of infancy or early childhood. • Instead of losing weight, children and adolescents who have not completed growth may not maintain weight or height increases along their developmental trajectory. • In severe cases, particularly in infants, malnutrition can be life threatening.
    • Diagnostic Features • Examples of individuals requiring supplementary feeding include: – Infants with failure to thrive who require nasogastric tube feeding – Children with neurodevelopmental disorders who are dependent on nutritional complete supplements – Individuals who rely on gastrostomy tube feeding or complete oral nutrition supplements in the absence of an underlying medical condition.
    • Diagnostic Features • In some individual, food avoidance or restriction may be based on the sensory characteristics of qualities of food, such as extreme sensitivity to appearance, color, smell, texture, temperature ,or taste. • Such behavior has b en d scribed as "restrictive eating," "selective eating," "choosy eating," "perseverant eating," "chronic food refusal," and "food phobia" and may manifest as refusal to eat particular brands of foods or to tolerate the smell of food being eaten by others. Individuals with heightened sensory sensitivities associated with autism may show similar behaviors.
    • Diagnostic Features • Food avoidance or restriction may also represent a conditioned negative response associated with food intake following, or in anticipation of, an aversive experience, such as choking; a traumatic investigation, usually involving the gastrointestinal tract (e.g., esophagoscopy); or repeated vomiting. • The terms functional dysphagia and globus hystericus have also been used for such conditions.
    • Associated Features Supporting Diagnosis • Several features may be associated with food avoidance or reduced food intake, including: – lack of interest in eating or food, leading to weight loss or faltering growth. – Very young infants may present as being too sleepy, distressed, or agitated to feed. – Infants and young children may not engage with the primary caregiver during feeding or communicate hunger in favor of other activities. – In older children and adolescents, food avoidance or restriction may be associated with more generalized emotional difficulties that do not meet diagnostic criteria for an anxiety, depressive, or bipolar disorder, sometimes called "food avoidance emotional disorder."
    • Development and Course • Most commonly develops in infancy or early childhood and may persist in adulthood. • Avoidance based on sensory characteristics of food tends to arise in the first decade of life but may persist into adulthood. • Avoidance related to aversive consequences can arise at any age. • Food avoidance or restriction based on sensory aspects is relatively stable and long-standing, but when persisting into adulthood, such avoidance/restriction can be associated with relatively normal functioning.
    • Development and Course • There is currently insufficient evidence directly linking avoidant/restrictive food intake disorder and subsequent onset of an eating disorder. • Infants with avoidant/restrictive food intake disorder may be irritable and difficult to console during feeding, or may appear apathetic and withdrawn. • In some instances, parent-child interaction may contribute to the infant's feeding problem (e.g., presenting food inappropriately, or interpreting the infant's behavior as an act of aggression or rejection).
    • Development and Course • Inadequate nutritional intake may exacerbate the associated features (e.g., irritability, developmental lags) and further contribute to feeding difficulties. • Associated factors include infant temperament or developmental impairments that reduce an infant's responsiveness to feeding. • Coexisting parental psychopathology, or child abuse or neglect, is suggested if feeding and weight improve in response to changing caregivers. • In infants, children, and prepubertal adolescents, avoidant/ restrictive food intake disorder may be associated with growth delay, and the resulting malnutrition negatively affects development and learning potential.
    • Development and Course • In older children, adolescents, and adults, social functioning tends to be adversely affected. Regardless of the age, family function may be affected, with heighten distress at mealtimes and in other feeding or eating context involving friend and relatives. • Avoidant/restrictive food intake disorder manifest more commonly in children then in adults • There may be a long delay between onset and clinical presentation. Triggers for presentation vary considerably and include physical, social , and emotional difficulties .
    • Risk and Prognostic Factors • Temperamental - Anxiety disorders, autism spectrum disorder, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder may increase risk. • Environmental - Environmental risk factor's include familial anxiety. Higher rates of feeding disturbances may occur in children of mothers with eating disorders. • Genetic and physiological - History of gastrointestinal conditions, gastroesophageal reflux disease, vomiting, and a range of other medical problems has been associated with feeding and eating behaviors characteristic of avoidant/restrictive food intake disorder.
    • Gender-Related Diagnostic Issues • Avoidant/restrictive food intake disorder is equally common in males and females in infancy and early childhood. • Avoidant/restrictive food intake disorder comorbid with autism spectrum disorder has a male predominance. • Food avoidance or restriction related to altered sensory sensitivities can occur in some physiological conditions, most notably pregnancy, but is not usually extreme and does not meet full criteria for the disorder.
    • Diagnostic Markers • Diagnostic markers include: – malnutrition – low weight – growth delay – need for artificial nutrition in the absence of any clear medical condition other than poor intake.
    • Functional Consequences of Avoidant/Restrictive Food Intake Disorder • Associated developmental and functional limitations include: – Impairment of physical development – Social difficulties – Significant negative impact on family function.
    • Differential Diagnosis • Appetite loss preceding restricted intake is a nonspecific symptom that can accompany a number of mental diagnoses. Avoidant/restrictive food intake disorder can be diagnosed concurrently with the disorders below if all criteria are met, and the eating disturbance requires specific clinical attention. • Other medical conditions – gastrointestinal disease – food allergies and intolerances – occult malignancies
    • Differential Diagnosis – Specific neurological/neuromuscular, structural, or congenital disorders and conditions associated with feeding difficulties. – Reactive attachment disorder – Autism spectrum disorder – Specific phobia – social anxiety disorder (social phobia) – other anxiety disorders – Anorexia nervosa – Obsessive Compulsive Disorder – Major Depression Disorder – Schizophrenia spectrum Disorder – Factitious Disorder
    • DSM-5 Diagnostic Criteria for Anorexia Nervosa A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. The word “refusal” was omitted as this was viewed as possibly pejorative and difficult to assess, as it implies intention. Rewording of the criterion to focus on behaviors was recommended. Significantly low weight - > BMI 18.5
    • DSM-5 Diagnostic Criteria for Anorexia Nervosa B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight . Clarification with regard to “fear of weight gain” took place. A significant minority of individuals with the syndrome explicitly deny such fear. Therefore, the addition of a clause to focus on behavior was recommended.
    • C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. DSM-5 Diagnostic Criteria for Anorexia Nervosa
    • DSM-5 Diagnostic Criteria for Anorexia Nervosa Criterion D was removed which is a substantial change to the DSM-IV, where amenorrhea is required to meet an eating disorder diagnoses. However, individuals have been clearly described who exhibit all other symptoms and signs of Anorexia Nervosa but who report at least some menstrual activity. In addition, this criterion cannot be applied to pre-menarchal females, to females taking oral contraceptives, to post-menopausal females, or to males. However, there are some data that women who endorse amenorrhea have poorer bone health than do women who fail to meet this criterion.
    • DSM-5 Diagnostic Criteria for Anorexia Nervosa • Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. • Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). It was recommended that the sub-typing be specified for the last 3 months.
    • DSM-5 Diagnostic Criteria for Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, In a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. A sense of lack of control over eating during the episode e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent Inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
    • DSM-5 Diagnostic Criteria for Bulimia Nervosa C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. Criterion C is a modest change to DSM-IV. DSM-IV requires that episodes of binge eating and inappropriate compensatory behaviors both occur on average twice/week over the last three months. A literature review found that the clinical characteristics of individuals reporting a lower frequency of once/week were similar to those meeting the current criterion. Therefore, it was recommended that the required minimum frequency be reduced to once/week over the last three months.
    • D. Sell-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. DSM-5 Diagnostic Criteria for Bulimia Nervosa
    • Sub-types have been deleted. DSM-IV requires that sub-type (purging or non-purging) be specified. A literature review indicated that the non-purging subtype had received relatively little attention, and the available data suggested that individuals with this subtype more closely resembled individuals with Binge Eating Disorder. In addition, precisely how to define non-purging inappropriate behaviors (e.g., fasting or excessive exercise) was considered to be unclear. DSM-5 Diagnostic Criteria for Bulimia Nervosa
    • DSM–5 new diagnosis Binge Eating Disorder A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances 2. a sense of lack of control over eating during the episode e.g., a feeling that one cannot stop eating or control what or how much one is eating)
    • B. The binge-eating episodes are associated with three (or more) of the following: 1. eating much more rapidly than normal 2. eating until feeling uncomfortably full 3. eating large amounts of food when not feeling physically hungry 4. eating alone because of being embarrassed by how much one is eating 5. feeling disgusted with oneself, depressed, or very guilty after overeating. DSM–5 new diagnosis Binge Eating Disorder
    • C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for three months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (i.e., purging) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa DSM–5 new diagnosis Binge Eating Disorder
    • Other specified Feeding or Eating Disorders including the following: 1. Atypical Anorexia Nervosa all criteria for anorexia nervosa are met except that despite significant weight loss, the individual’s weight is within or above the normal range. 2. Sub threshold Bulimia Nervosa (of low frequency and/or limited duration) all of the criteria for bulimia nervosa are met, except the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months. 3. Sub threshold Binge Eating Disorder (of low frequency or limited duration) all criteria for binge eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months.
    • 4. Purging Disorder (PD): Recurrent purging behavior to influence weight or shape, (e.g., self-induced vomiting, misuse of laxatives, diuretics, or other medications) in the absence of binge eating. 5. Night Eating Syndrome (NES): Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep/wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by Binge Eating Disorder or another mental disorder, including substance use, and is not attributable to another medical disorder, or an effect of medication. Other specified Feeding or Eating Disorders
    • Unspecified Feeding or Eating Disorder which is a residual category for all other cases that are clinically significant but do not meet the criteria for formal eating disorder diagnoses
    • DSM-IV diagnosis total 2,548
    • ED-NOS to DSM-5 total 1030 0% 5% 4% 19% 5 % AN-R AN-BP BN BED FEDNEC
    • FEDNEC subtypes total 524
    • 41% ED-NOS > 21 % FEDNEC > 12% mixed